COMMON OFFICE EMERGENCIES

R. John Brewer EMT-PDental Education Inc.

Blood Pressure - Hypertension

Every office should establish guidelines for treatment

What is the patient’s baseline pressure?

If hypertension is noted, what is the cause?

Is it acute or is it chronic? If it is acute without symptoms, allow the patient

to rest and recheck in 5-10 minutes

Blood Pressure - Hypertension

If it persists, refer to physician

If it resolves to baseline or near baseline proceed with treatment, if comfortable

If it is acute with symptoms (headache, tinnitis) send to emergency department

You can often be the first-line defense in referring patients with chronic blood pressure elevation to see a physician

Hypertension

Normal <130 Systolic < 85 Diastolic

High Normal 130-139 85-89

Stage I HTN 140-159 90-99 150/90 > age 60Stage 2 HTN 160-179 100-109

Hypertension

Stage 3 HTN 180-209 110-119 patient should see MD within one week.

Stage 4 HTN >210 => 120.00

Blood Pressure - Hypertension Treatment of hypertension

Rest and relax, make sure patient took prescription medication.

Contact physician, determine whether immediate consult or ED is warranted

With symptoms, administer oxygen, monitor

Nitroglycerin - sublingual tablet or spray (0.4mg) every 5 minutes as needed.

Continue to monitor

Postural Hypotension

Also known as orthostatic hypotension.

It is the second leading cause of loss of consciousness in the dental office.

Postural hypotension is defined as a disorder of the autonomic nervous system in which syncope occurs when the patient assumes an upright position.

Postural hypotension

Postural hypotension may also be defined as a drop in blood pressure of 30mm hg or >10mm hg drop in diastolic pressure upon standing.

Usually not associated with fear or anxiety.

Knowing predisposing factors can allow the dentist to prevent this from occurring.

Predisposing factors

Administration and ingestion of drugs Prolonged period of recumbence or

convalescence Inadequate postural reflex Late-stage pregnancy Advanced age Venous defects Addison's disease Physical exhaustion/starvation

Blood Pressure - Hypotension

For young healthy people, blood pressure can almost never be too low.

For more medically compromised patients low blood pressure can be a problem

With signs of mental status changes or dizziness, a low blood pressure can be a problem, again either acute or chronic.

Postural Hypotension

Patient will report feeling light headed or lose consciousness with positional changes.

Return to supine position as quickly as possible.

Symptoms will resolve rapidly.

Raise chair back incrementally, sit with feet on floor, stand without walking.

Resume standing position slowly

Postural hypotension

Management- Assess level of consciousness- Activate office emergency system- Place patient supine- CAB’s- 02 administration- 911 vs. discharge- Don’t allow patient to drive

Postural hypotension

Examples:

Middle age male, semi reclined, injected with local. Dr. and eventually staff member walk out of room. Patient begins to feel funny, sits up, leans forward. A loud crash is heard next, staff finds patient unconscious and bleeding.

Another example

Elderly patient develops syncope whose recumbent blood pressure was 180/100 and dropped to 100/50 after standing.

Middle age patient in chair for approx 1 hour stands up walks to reception desk while standing still feels faint loses consciousness.

CHEST PAIN

Chest Pain/Acute Coronary Syndrome

Each year 1.1 million Americans suffer a heart attack.

Approx 460,000 of these are fatal. Approx ½ of these deaths occur within

the first hour of the onset of symptoms. National statistics show that approx. 5%

of all AMI’s are misdiagnosed and discharged from the ED

Results in the most malpractice dollars spent.

Acute coronary syndrome

ACS - a temporary or permanent blockage of a coronary artery.

ACS can include unstable angina, STEMI, NSTEMI.

Sudden cardiac arrest can occur with any of these conditions.

Stable Plaque

Unlikely to rupture Mainly made up of collagen-rich tissue

that has hardened. Have a thick fibrous cap over the lipid

core which separates it from contact with the blood.

As these plaques increase in size, the artery becomes severely narrowed. Symptoms begin when approx 70% of the vessel is narrowed.

Pathology

The most common cause of ACS is plaque rupture.

Two types of plaque Stable vulnerable

Vulnerable Plaque

These are plaques that are prone to rupture.

Soft, and have a thin cap of fibrous tissue over the fatty center which separates it from the opening of the artery.

Platelets stick to the damaged lining within 1-5 seconds.

Vulnerable Plaque

“sticky platelets secrete many chemicals which include Thromboxane A2. This drug stimulates vasoconstriction, which in return decreased blood flow.

Aspirin blocks the production of Thromboxane A2. This slows down the clumping of platelets and lowers the risk of complete blockage of the vessel.

Causes of Plaque Rupture

Severe emotional trauma Sexual activity Use of cocaine, marijuana,

amphetamines Exposure to cold Acute infection

Contributing factors

Coronary spasm at the site of the plaque

Effects of the other risk factors

Blockage of Coronary Artery Two types:

Complete which may result in STEMI or Sudden death.

Partial –may result in no clinical signs or symptoms (silent MI) unstable angina, NSTEMI or even sudden death.

Angina Pectoris

Chest discomfort that occurs when the heart muscle does not receive enough oxygen.

Angina is not a disease. It is a symptom of myocardial ischemia.

Angina most often occurs in patients with know CAD, involving at least one coronary artery.

Angina

Common sites for pain include the following: upper chest, substernal radiating to neck

and jaw. Beneath sternum radiating down left

arm. Epigastric or epigastric radiating to

neck, jaw, arms. Left shoulder pain Back pain between shoulder blades. Right arm pain.

Angina

Terms used to describe discomfort:- Heaviness- Pressing- Suffocating- Squeezing- Constricting- Burning- Grip like- Band, weight, vise on or around chest

Angina

Terms used to describe discomfort:- Heaviness- Pressing- Suffocating- Squeezing- Constricting- Burning- Grip like- Band, weight, vise on or around chest

Angina Equivalents

- Generalized weakness- Difficulty breathing- Diaphoresis- Nausea, vomiting- Dizziness- Syncope, or near syncope

Angina

- Palpitations- Isolated arm or jaw pain- Fatigue- Arrhythmias

Angina

Three Types:

- Stable

- Unstable

- Prinzmetal’s

Angina

Stable- Constant, predictable in terms of

severity- Signs symptoms, precipitating

events, and response to treatment. - Usually lasts 2-5 minutes.

Angina Remember, 1st sign of chest pain is often not

angina when it occurs in the dental office

Be careful with epinephrine dosage

Healthy patients can receive .2 mg of epinephrine

In cardiac patients stay below .04 mg

Angina

Unstable Condition between stable angina and

acute MI. Occurs most often in men and women

between ages of 60-80 who have one or more major risk factors of CAD.

Patients with untreated unstable angina are at high risk of heart attack or death.

Unstable Angina

Unstable angina symptoms usually occur at rest. These symptoms last > 20 minutes.

These symptoms are new maybe over the past several weeks becoming progressively worse.

Prinzmetal’s Angina

Defined as intense spasm of segment of coronary artery.

May occur in healthy individuals between 40-50 years of age, with no CAD.

Prinzmetal’s

Occurs at rest Occurs in the early morning hours and

may awaken patient from sleep.

Episodes may only last a few minutes but may be long enough to cause v-fib,v-tach, and sudden death.

If spasm persists may cause infarct.

Myocardial Infarction

Ischemia prolonged more than just a few minutes results in myocardial injury.

Injury refers to myocardial tissue that has been cut off from its blood or oxygen supply.

Injured cells are alive but will die (infarct) if ischemia is not quickly corrected.

The corrective actions include: fibrinolytics, angioplasty, stent, CABG

M.I.

We should think of MI as a continual process, not as a dead heart.

If efforts are made to recognize and treat promptly, the loss of heart muscle may be avoided.

MI

Most MI’s result of a Thrombus . Less common it is a result of coronary spasm. Ex. Cocaine abuse.

Nearly 10% of MI’s occur in people under 40.

Nearly 45% of MI’S occur in people under 65.

60% of all MI’s arrive in ED by private vehicle.

MI

Initial Management CAB’s Oxygen 2-4 liters via nasal cannula Vital signs ( pulse, blood pressure) SAMPLE History

Treating the MI

Call 911 Oxygen Aspirin 3-4 81 mg chewable

allows for quicker absorption can rival fibrinolytic therapy in its impact on

mortality reduction.

Treatment

Nitroglycerine 0.4mg sub lingual

Relaxes smooth muscle

Results in Venodilation

Decreases oxygen demand

NTG

Prior to administering NTG : Systolic BP> 100 Heart rate >50 < 100 Patient has not used Viagra,

Cialis ,Revatio with the past 24-48 hours.

Repeat ntg q. 5 min. as long as BP> 100

Cardiac Arrest

Heart rhythms can be shockable.(V-fib/V-Tachycardia)

Heart Rhythms can be non-shockable( asystole/PEA

Patient will be immediately unconscious

Assess CAB’s Call 911/ Get AED Begin Chest Compressions

Cardiac Arrest

Attach AED (automated external defibrillator)

Follow voice prompts from defibrillator

Continue Chest Compressions Begin Ventilations If trained advanced airway

placement(I-Gel)

RESPIRATORY SYSTEM

ASTHMA

Asthma

Is a very common medical emergency

Approx. 17 million Americans suffer from asthma.

There are more than 2 million visits to the ED with asthma.

Approx. 5000-6000 deaths each year.

Asthma is defined as a chronic inflammatory disorder of the airways. This inflammation results in airflow obstruction.

Asthma attacks are reversible, they are usually brought on by one of the 3 “Ss”

Spasms Swelling Secretions

Asthma is categorized into two types.

- Extrinsic Asthma

- Intrinsic Asthma

Extrinsic Asthma

Also known as allergic asthma

50% of asthmatics have this form or asthma.

Most common in children and young adults.

Extrinsic asthma

The allergen may be airborne such as dust, latex. Etc…..

The allergen may be ingested such as foods, medications.

Once exposed bronchospasm can develop within minutes.

Intrinsic Asthma

Affects the other 50% of asthmatic patients

Usually develops in older adults > 35 years of age.

Also known as nonallergic, idiopathic, or infective asthma.

Intrinsic asthma

Causes:-viral infection is most common

- Exercise induced

- Psychological and physiologic stress

Status Asthmaticus

Most severe form of asthma

Experience wheezing, dyspnea, hypoxia that are refractory to B-adrenergic agents.

This is a true medical emergency

Asthma Signs and Symptoms

Chest congestion Cough Wheezing Dyspnea Use of accessory

muscles Confusion Retractions

Anxiety Apprehension Tachypnea Increase in BP Tachycardia Diaphoresis Cyanosis Nasal Flaring

management

Terminate dental procedure 911 Position of comfort Reassure patient Oxygen Administration Albuterol 2.5mg/3cc nss via 02 powered nebulizer at

6 liters per minute. Or 2 puffs of ventolin inhaler.

If severe enough, epinephrine .3 mg IM (1:,1000)

Emphysema “Pink puffers”, barrel chest Not likely to see an acute emergency from

emphysema Treat as upright as possible If there is breathing difficulty with the patient,

have him/her exhale through pursed lips Oxygen never hurts 2.5 mg albuterol/3cc nss via 0xygen powered

nebulizer @ 6lpm.

Chronic Bronchitis

“Blue Bloaters” Again, not a disease that will cause an

acute emergency Treat as upright as possible 2.5mg albuterol/3cc nss via o2 powered

nebulizer @ 6 liters per minute.

Aspiration Foreign body airway obstruction Most cases can be avoided with diligent

suctioning or use of ligatures If object goes missing it will end up in

several different places Back of throat Larynx Lungs Stomach

Aspiration

All objects must be accounted for Even if patient says he/she did not

swallow or aspirate object, a chest x-ray must be done to confirm whereabouts

If swallowed follow-up for several days If fully aspirated, treatment will

depend on location, size, and type of material

Aspiration

Objects that get lodged in the larynx will cause either full or partial airway obstruction

Allow patients to manage a partial airway obstructions as long as they can phonate or until lose of consciousness

Full airway obstruction must be managed immediately with the Heimlich maneuver

Aspiration

As long as the patient is conscious, he will want to sit or stand up, let him .

Once consciousness is lost, supine position, begin 30 chest compressions, look in airway , and attempt to ventilate. Repeat procedure until object is dislodged or able to ventilate.

Dyspnea

Dyspnea is one of the most common medical complaints.

Usually described as “short of breath.” Not associated with any one disease Many different causes: CVS, CNS, RS,

endocrine system, immune system Any mechanism that causes hypoxia.

Dyspnea

The Dyspnea may be mild, to severe.

The dyspnea may occur with exertion or may start while at rest.

Dyspnea

Immediate concerns include:-Is the airway patent and stable?

What is the rate and depth of respirations

Is the patient hypoxic

Normal or abnormal breath sounds.

Dyspnea

History of Respiratory disease?

Onset sudden or gradual?

Any chest pain?

Evidence of infection?

What medications?

Dyspneadifferential diagnosis Pulmonary etiologies-Acute Asthma

-Anaphylaxis

- Aspiration

- Pulmonary embolism

Differential diagnosis

Cardiac etiologies

- Acute MI

- Pulmonary Edema

Differential Diagnosis

Non Cardiac and Non Pulmonary causes

- Anemia

- Hyperventilation

Dyspnea

Key Physical Findings

-Mental Status - Look for signs of shock - vital signs including lung sounds

Dyspnea

Key Physical Findings

- Skin

- Accessory Muscles

- extremities

Treatment

Administer oxygen Monitor closely Call for assistance If significant respiratory distress is

present, patient may stop breathing or gasp (agonal)

If respirations are not sufficient to maintain oxygenation, assist with positive pressure

If breathing stops, maintain at rate of 12-20 per minute, do not forget about checking CVS

CENTRAL NERVOUS SYSTEM

Hyperventilation

Brought on by anxiety, it is a very common medical emergency in the dental office.

Occurs in the apprehensive patient who attempts to hide their fears.

More common in young females

Hyperventilation

Hyperventilation occurs when respiration exceeds the metabolic demands of the patient.

The concentration of carbon dioxide in the blood is reduced below base levels.

Manifested by increase in tidal volume, rate or both.

Hyperventilation

Characterized by rapid breathing, chest pains

Numbness to extremities, muscle pain, cramps

Feeling faint, lightheaded, dizzy, Nervousness, anxiety Tingling around mouth

Hyperventilation

In a purely anxious patient the excess elimination of CO2 causes respiratory alkalosis. This in return causes hypocalcemia.

This hypocalcemia results in cramping of the muscles in the hands and feet. This is known as carpal-pedal spasms.

Hperventilation

However Hyperventilation may be a sign of other medical problems.

Hyperventilation should always be considered a major medical problem until proven otherwise.

Hyperventilation

Other causes include the following: cardiovascular causes CNS emergencies CHF COPD Drugs, Fever Hypotension

Hypoxia Metabolic disorders Pain Lung problems

Hyperventilation

Management The goal should be to correct the

respiratory problem, and to reduce anxiety.

Therefore the first step is to stop the dental procedure.

Place patient in position of comfort.

management

Monitor ABC’s Coach breathing 02 at low flow with mask(1-2 liters) NEVER NEVER have patient breath

into paper bag. !!! If symptoms do not resolve contact

911.

SYNCOPE

Syncope defined

A neurological condition characterized by the sudden, temporary loss of consciousness caused by insufficient blood flow to the brain. Usually recovery is almost immediate upon becoming supine.

If a patient does not spontaneously regain consciousness within a few moments(usually less that 1 minute) it is NOT syncope, it is something more dangerous.

syncope

½ of all Americans will experience at least one episode of syncope during their lifetime.

According to the National Institutes of Health, Syncope accounts for 3% of all emergency dept. visits.

Most Common emergency in the office

Predisposing factors

Anxiety, stress, pain Sight of blood or dental syringe Erect sitting or prolonged standing Hunger and exhaustion Hot humid crowded environment

Phases of Syncope

Pre-Syncope Syncope Post -Syncope

Pre-Syncope

Anxiety, stress , pain triggers the “flight, fight response”

Rapid release of epinephrine and nor-epinephrine

Blood pools in periphery

Signs,symptoms pre syncope Warm flushed feeling face and neck Pale ashen skin color Cold diaphoretic Nausea Lightheaded Pupils dilate Yawning Tachycardia with slight hypotension

Syncope phase

Patient loses consciousness Generalized relaxation of muscles Bradycardia Seizure Eyes open with upward gaze

Post syncope phase

Rapid return to consciousness if treated properly

If LOC> 1 min. EMS needs to be contacted immediately if not already contacted.

Short period of confusion Headache may persist for hours Slow return to pre syncope heart

rate and blood pressure.

Types of Syncope

Vasovagal syncope

Cardiac syncope

Orthostatic syncope

Neurogenic/neurologic

Miscellaneous

Vasovagal

Most common More common in young males Most benign “simple fainting” Differential diagnosis: remember

with simple fainting the patient is ALWAYS sitting erect or standing when symptoms occur.

Cardiovascular syncope

Mechanical problems Dysrhythmias - Bradycardia vs.

tachycardia

Heart rates < 50 and greater than 150 should be a concern and may be signs of serious cardiac event.

Orthostatic hypotension

Syncope when going from a sitting or supine position to a standing position.

May be caused by hypovelemia/dehydration

Medications that reduce vasoconstriction such as ACE inhibitors may make patients prone to these orthostatic changes. Examples of ACE are:enalapril,captopril,lisinopril ramipril

Neurogenic/neurologic

Stroke is a rare cause of syncope A subarachnoid hemorrhage can

cause syncope followed by a severe headache.

Carotid sinus syndrome (turning the head to one side)may cause syncope

Miscellaneous causes

Hypoxia

Hypoglycemia

hyperventilation

Critical points

Any patient developing syncope without warning symptoms , or while in the supine position must be assumed to have a cardiac cause for syncope until proven otherwise.

Positive orthostatic vital sign changes in a patient are a strong indication of decreased circulating blood volume.

treatment

Stop all dental work Remove objects from mouth Place patient supine Maintain airway using head tilt –chin

lift method. Administer 0xygen- assist ventilations

if needed Vitals- pulse, resp. BP. Monitor, Always remember to call 911

Preventing syncope

Comfortable temperature in operatory

Supine position Avoid hypoglycemia Supplemental oxygen therapy Stress reduction protocol

STROKE

Stroke

A sudden change in neurologic function caused

by a change in cerebral blood flow.

A stroke is also called a “ Brain Attack”

Stroke facts

Patients who have a-fib are 5-17 times more likely to develop a stroke than those who do not have a-fib.

About 1-2% of all patients who an acute MI have a subsequent stroke within the first month after their cardiac event. Half of these occur with the first 5 days of the MI

Types of Stroke

Ischemic

Hemorrhagic

Ischemic Stroke

Accounts for approx. 80% of all strokes

Two types of Ischemic Strokes

-Thrombotic

-Embolic

Embolic Stroke

Clots arise elsewhere in the body and migrate to the brain. (Cerebral embolism)

Thrombotic Stroke

Most common cause of stroke

Atherosclerosis of large vessels in the brain causes progressive narrowing and platelet clumping.

Blood clots develop within the brain artery itself ( cerebral thrombosis)

Symptoms of Stroke

Paralysis or weakness

Altered mental status including impaired memory and / or judgment.

Sensory deficits

Impaired gait

Symptoms of Stroke

Visual disturbances

Pinpoint, dilated or unequal pupils

Aphasia

Slurred speech

Difficulty in speaking, getting thoughts out

Symptoms of Stroke

Vertigo

Syncope

Vomiting

Headache

Symptoms of Stroke

Seizures

Unconsciousness

Bowel or bladder incontinence

Abnormal respiratory patterns

Acute Stroke- Early Diagnosis Trauma - “ Golden Hour”

Heart Attack - “Time is Muscle”

Stroke - “Time is Neurons” “Time is Brain”

StrokeEarly Recognition/Treatment

The earlier the intervention, the better the results

Window of opportunity to use tPA

< 4 1/2 hours required for IV fibrinolytic therapy

<6 hours required for intra-arterial fibrinolytic therapy

Hemorrhagic Stroke

Spontaneous intracranial hemorrhage responsible for 8-11% of all acute strokes.

Bleeding forms a hematoma that causes local injury, decreased tissue perfusion and increased intracranial pressure.

Predisposing conditions include HTN, oral contraceptives, cocaine use and anticoagulant and antiplatelet agents.

Stroke-Chain of recovery

Identify Dispatch EMS arrival Alert Stroke Team Diagnosis and Treat Transport and Evaluation Rehab

Cincinnati PrehospitalStroke Scale

Facial droop/weakness- Ask patient to “smile for me”

- Motor weakness(arm drift)- With eyes closed, ask patient to

extend arms in front of him or her.

- Aphasia or slurred speech.

Stroke- Initial Care

Assess CAB’s and vital signs , check BP in both arms.

Check pulse ox and administer 02 as indicated

Start IV, and check blood glucose

SEIZURES

Seizures

Defined as a temporary alteration in behavior due to the massive electrical discharge of one or more groups of neurons in the brain.

Causes of Seizures

May be brought on by stressors to the body.

Examples include- Hypoxia- Hypoglycemia- Hypothermia- Hyperthermia

Causes of Seizures

Seizures may also be caused by diseases such as:

Tumors Head Trauma Toxic Eclampsia Vascular disorders

The most common however is Idiopathic Epilepsy.

Types of Seizures

Generalized seizures - Tonic-Clonic - Absence

Partial Seizures - Simple partial seizures - complex partial seizures

SEIZURES

Tonic Clonic – also known as a grand-mal seizure is generalized motor seizure producing a loss of consciousness.

The patients intercostal muscles, diaphragm become temporarily paralyzed, interrupting respirations and produces cyanosis.

Phases of generalized seizures

Aura Loss of consciousness Tonic phase Hypertonic phase Clonic phase Post seizure Postictal

Phases of generalized seizures

Aura Loss of consciousness Tonic phase Hypertonic phase Clonic phase Post seizure Postictal

Absence Seizures

Absence seizure also known as petit mal seizure.

Described as a 10-30 second second loss of consciousness or awareness.

Idiopathic disorder of childhood, rarely occurs after the age of 20.

Pseudo seizures

Pseudo seizures are also know as "hysterical seizures.”

Occur as a result of psychological disorder.

Patients present with sharp bizarre movements which can be interrupted with a tense command .

Partial Seizures

There are two types of Partial seizures.

Simple partial seizures

Complex partial seizures

Simple Partial Seizures

Also known as focal seizures. Characterized by chaotic movement

of one area of the body. They may progress to generalized

seizures.

It is very important to document how seizures begin and the progression they take.

Complex Partial Seizures

Complex partial seizures are also know as temporal lobe or psychomotor seizures.

Characterized by distinctive auras such as unusual tastes, smells, or sounds.

Seizures usually last 1-2 minutes. Patient may act confused, stagger

perform purposeless movement, or make unintelligible sounds.

Some patients show sudden change in personality.

Assessment ofthe Seizure Patient

Many medical emergencies may mimic a seizure.

- migraines -cardiac emergencies - hypoglycemia - drug ingestion syncope

assessment

A good history will help you determine if it is a true seizure. Some important information that should be obtained is the following:

History of Seizures Recent history of head trauma Recent history of fever, headache,

stiff neck History of diabetes , heart disease ,

stroke Current medications

Seizures

Commonly seizures occur in a patient who is non compliant with medications, or needs an adjustment in dosage or intervals.

Seizure vs. Syncope

Seizures typically involve tongue biting, incontinence and a period of postictal confusion.

Seizure etiologies

Primary seizures –(Epilepsy) unprovoked, intermittent, recurring seizure activity.

Secondary- predictable responses to toxins, or environmental or pathophysiological events.

Hypoxic seizures- caused by inadequate airway or ventilation.

Seizure etiologies

Alcohol or drug induced – look for signs of overdose, pertinent history of alcohol or drug abuse.

Intracranial insults- infections, trauma, strokes, tumors.

Fever Eclampsia-

Managing theSeizure Patient

Call 911 Maintain airway Administer High flow oxygen Establish IV NSS Determine Blood Glucose Maintain body temperature Suction if needed If seizure > 5min.consider anticonvulsant . Versed 1-2mg IV Push or IN Can be repeated after 10 minutes

Loss of Consciousness

May result from systems other than central nervous system: Respiratory - asthma, aspiration Cardiac - arrhythmia, cardiac arrest,

orthostasis Endocrine - hypoglycemia, thyroid Metabolic - electrolyte abnormalities,

dehydration Drugs Behavioral (Pseudo Seizures)

Loss of Consciousness

Until diagnosis is made, treat all LOC patients the same way Supine position, preferably on the floor Good airway management, will often be

enough to keep patient breathing or even arouse patient

Ventilate if needed Check circulation

Overdose

Narcotic overdose- Airway- Support Ventilations- 911

ENDOCRINE SYSTEM

Diabetes

Disease where sugar is available in the system but not to the cells

Type I - “insulin dependant diabetes” Do not produce any insulin Will need insulin to force sugar into the

cells More fragile than type II Have significantly more systemic

problems

Diabetes

May have peripheral neuropathies, renal failure (dialysis), retinal degeneration, atherosclerosis, poor circulation (ulcerations, amputations)

The more of these, the worse off the patient is

Physician consultation may not be a bad idea

Type II - “non-insulin dependant diabetes”, now see a lot of patients on insulin, do produce insulin, but not enough

Diabetes

Not as fragile Will tolerate periods of hypoglycemia

better Not as many significant systemic issues

Treat all diabetics on their normal schedule Unless there is reason for it, make sure

they take their medications and eat a normal diet

May need to work around dialysis schedule

Diabetes Signs and symptoms of Hypoglycemia:

Confused, unconscious Shallow respirations Pale, cool, damp Increased heart rate and blood pressure Blood Glucose < 80mg/dl

Signs and symptoms of Hyperglycemia: Confused, unconscious Increased respirations and heart rate Pale, warm, dry Decreased blood pressure

Hypoglycemia

Usually seen in diabetic patients, but not always

Diabetic will take insulin or oral hypoglycemic medication and not eat

Often seen with patients that are in pain and not on a normal diet

Be careful with long appointments, allow time to eat or drink if possible

Hypoglycemia

Most diabetics will be able to tell when their sugar is low

As long as they are conscious, administer an oral sugar source: Fruit drink

Cake icing

Hypoglycemia Symptoms should resolve fairly quickly

Cancel appointment and watch for approx. 30 minutes.

Attempt to have someone drive patient home.

If patient is unconscious: 911

IMMUNE SYSTEM

Allergic Reactions

Several different types and severities of hypersensitivity reactions Type I reactions - anaphylaxis/immediate Type II reactions - usually associated with

blood products Type III reactions - onset may not be seen

for several weeks - serum sickness or nephritis

Type IV reactions - delayed hypersensitivity, 24-72 hours after skin contact - latex

Allergic Reactions Our concerns are mostly with Type I

and IV reactions Obviously, a good medical history

will help prevent or eliminate most allergic reactions

As a general rule, reactions will be much more severe with IV or IM applications than with oral or topical applications

Allergic Reactions

Treatment of Type I reactions Recognition Severe anaphylaxis will manifest in all major

systems: Respiratory - wheezing, laryngeal

edema, respiratory distress, airway obstruction

Skin - angioedema, pruritis, flushing, lesions

Cardiovascular - hypotension, tachycardia, dizziness, syncope, cardiovascular collapse

Allergic Reactions

With appearance of even some of these signs, treat aggressively

Stop administration of suspected agent(s)

Initiate BLS protocol - CAB’s, oxygen 911 Epinephrine - .3mg IM (1:1,000)

Allergic Reactions Administer diphenhydramine, 25-50

mg IM

In a conscious patient with respiratory difficulty, give nebulized albuterol if available or 4-8 puffs of inhaler.

May need to give positive pressure to assist with respirations

Allergic Reactions

With less severe or delayed allergic responses give PO diphenhydramine, 25-50 mg orally every 4-6 hours

Alert physician to patient status Follow-up with phone call later Tell patient that if symptoms

worsen call 911.

Latex Sensitivity

Normally manifests itself as a delayed hypersensitivity reaction

Signs of contact dermatitis will show 4-6 hours after exposure and peak within 48 hours

Usually a sharp line where the latex was in contact with the skin

Latex Sensitivity Treatment is the same as for a minor

allergic reaction, PO diphenhydramine, 25-50 mg every 4-6 hours

Prevention is the best treatment Avoid latex gloves, rubber dams

Susceptible patients will report allergies to avocados, bananas, chestnuts, will have worked in health care or around natural rubber, or have spina bifida

Methemoglobinemia

Blood disorder in which an abnormal amount of methemglobin is produced.

The Hemoglobin is unable to release oxygen effectively to the bodies tissues.

Methemoglobinemia

Two Type:

Inherited

Acquired

Acquired is the most common.

Methemoglobinemia

ACQUIREDCaused by exposure to certain drugs,

chemicals or foods.

Most common cause in dental office would be the topical (Benzocaine)

Methemoglobinemia

Symptoms-Bluish color of the skin - Headache- Fatigue- Dyspnea- Lack of energy- Blood appears chocolate colored

Methemoglobinemia

Symptoms

- Abnormal cardiac rhythms

- Altered level of consciousness

- Seizures

Methemoglobinemia

TREATMENT

911

CAB’s

- Methylene Blue

- Hyperbaric oxygen Therapy

QUESTIONS?